Neurology & Pain Management Coding Alert

Question: Our neurologist saw a patient for muscle and range-of-motion testing on her right hand as well as a related problem-focused exam with straightforward medical decision-making. This is the first time this neurologist has seen the patient, but another neurologist in our group practice saw her for similar reasons about two years ago. How should I code for the encounter, and should I consider the patient to be new or established?

Pennsylvania Subscriber

Answer: For the patient's muscle and range-of- motion testing, your best coding choice is 95852 (Range-of-motion measurements and report [separate procedure]; hand, with or without comparison with normal side).

But that's not where your coding process ends in this case -- you may have to include the testing in the E/M code.

Because the patient saw another physician in your group practice within the previous 36 months, you-ll consider her to be established. According to CPT's E/M guidelines, an established patient "is one who has received professional [face-to-face] services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years."

You-ll use that information -- along with the type of E/M service the neurologist provides -- to select the correct E/M code.

Go to the "Office or Other Outpatient Services" section of CPT to select from the appropriate E/M code range. In this case, you-ll look at the codes for established patients (99211-99215) to make your final code selection, which is 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making).

Important note: You-ll also want to check the most recent national Correct Coding Initiative (CCI) edits, which shows that 95852 is included in 99212. This means that you should report only 99212. If you report both codes separately, you will receive a denial for 95852.

Where to look: You can find information on the CCI edits on the CMS Web site at http://www.cms.hhs.gov/NationalCorrectCodInitEd/.